SPEAC (Summer Programs East Asian Concentration)

Teacher-Training-Credit Option-OSU

PROGRAM YEAR 2015

Applicant Name ______

APPLICATION FORM FOR CREDIT OPTION OSU APPLICATION

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WHO SHOUD USE THIS APPLICAION FORM

Use this application only if (1) you need OSU credits for participation in this program (otherwise, use the form for the non-credit option applicants); (2) you are currently registered OSU student (otherwise, use the form for the non-OSU applicants; and (3) you are a U.S. citizen or a non citizen who has permanent resident, refugee, or asylee status (all other credit-option applicants should use the application form for international students).

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Training program in which language? (check one) Chinese Japanese

Levels of Training (Check one or both): Beginning Level (4 weeks) Intermediate Level (3 weeks)

I.  Personal Information

Name Date of Birth

Last Name First Name Middle Name Month / Date / Year

Name in Japanese / Chinese (if applicable)

The last 4 digits of your U.S. Social Security Number ______Sex Male Female

Current Mailing Address

City State (Prefecture, Province, etc.)

Zip(Postal)Code Country

Telephone (home) Telephone (Cell)

Permanent Address (if different from current address)

City State (Prefecture, Province, etc.)

Zip(Postal)Code Country

Permanent Phone Fax

OSU E-mail address Country of Citizenship

Place of Birth (City/Country) Permanent country of residence

What is your ethnic background? (check one) Black, non-Hispanic American Indian or Alaskan native

Asian or Pacific Islander Hispanic White, non-Hispanic

Emergency Contact (name)

Relationship (mother, etc.) _ Phone

Per the student’s designation the University may or may not release certain information about each student to the public or through the student directory. Please indicate whether or not you agree to Personal Information Release. Yes No

II.  Registration Information

Give last quarter and year attended

major/CAP college/school

Have you requested a transfer from one undergraduate enrollment unit (college, school or division) to another within the past year? Yes No

Have you resided in Ohio for the past 12 consecutive months? Yes No

Are you presently under suspension/dismissal from any post-high school education, including Ohio State? Yes No

If yes, please attach a statement of explanation.

Is your cumulative point hour ratio (CPHR) a 2.00 (C) or higher on a 4.00 for all previous college work in the United States?

Yes No

III.  Educational background (List all post-secondary institutions attended, beginning with current or most recent)

Institution (Name) / Address
(City, Country) / Dates Attended
From (Mo/Yr)
To (Mo/Yr) / Major or Program / Degree / Date Received (Mo/Yr)

IV.  Experience in Teaching Chinese/Japanese (Begin with current or most recent)

Institution / Dates / Materials Used / Levels Taught

V.  Other Relevant Professional Work Experience (Begin with current or most recent)

Company/Institution / Location / Dates / Position/Duties

Have you attended a US institution of higher education as a full-time degree candidate? Yes No

VI.  If you are not a native speaker of English, provide information for the following.

Evaluate your own ability in English according to the scale below. (Circle your response.)

5 (Very High) 4 (High) 3 (Above average) 2 (Low) 1 (Minimal) X (unknown)

Ability to engage in professional discourse: 5 4 3 2 1 X

Ability to engage in daily conversation: 5 4 3 2 1 X

Sensitivity to different aspects of language use: 5 4 3 2 1 X

Ability to read professional documents: 5 4 3 2 1 X

Ability to read simple documents: (e.g. letters, memo) 5 4 3 2 1 X

Ability to present own thinking in coherent writing: 5 4 3 2 1 X

VII.  If you are not a native speaker of the target language (Japanese or Chinese), provide information for the following.

Target language for teacher training in SPEAC (check one) Chinese Japanese

Evaluate your ability in the target language according to the scale below. (Circle your response.)

5 (Very High) 4 (High) 3 (Above average) 2 (Low) 1 (Minimal) X (unknown)

Ability to engage in professional discourse: 5 4 3 2 1 X

Ability to engage in daily conversation: 5 4 3 2 1 X

Sensitivity to different aspects of language use: 5 4 3 2 1 X

Ability to read professional documents: 5 4 3 2 1 X

Ability to read simple documents: (e.g. letters, memo) 5 4 3 2 1 X

Ability to present own thinking in coherent writing: 5 4 3 2 1 X

VIII. Health Insurance:

You are automatically enrolled in single Comprehensive coverage unless you complete the online waiver form by the deadlines. You will be required to provide proof of comparable coverage with the waiver request. Please see the instruction in the following link. http://shi.osu.edu/selection-and-waiver-instructions/waiving-procedures/. Information regarding the health insurance requirement, the Student Health Insurance Plan, and the deadline for enrollment/withdrawal is located at http://shi.osu.edu/.

IX. Personal Statement

Please describe in English your purpose in applying for the SPEAC intensive language program (Chinese or Japanese) and your academic and professional goals as they relate to the program. Limit your comments to 3200 characters (including space).

IX. References

Please name two people who, in their professional capacities, can talk about your character and academic readiness to undertake the intensive study of Chinese or Japanese. You need not require them to write a letter of recommendation, but please let them know that as a reference person they may be contacted. Please note that family members are not eligible. Please list the names of the two people you have asked to be references.

Name / Title / Institution

XI. Statement of Intention and signatures

The SPEAC Language Programs are intensive studies in the Chinese or Japanese language. The course of study requires individuals to be in classes from four to five hours each day, and to spend between several hours daily preparing for classes. Students participating in this program are not permitted to take other classes or hold full time jobs without prior written permission; part-time employment is also strongly discouraged.

SPEAC program fees do not include Student Health Insurance, housing and meals.

Participant’s failure to abide by these provisions may result in his/her disenrollment in SPEAC.

I fully understand the nature of SPEAC and will abide by the requirements and guidelines of the program.

Signature: ______Date ______

I affirm that the information I have provided on this application form and any additional information I submit related to the admissions/financial aid process is complete, accurate, and true to the best of my knowledge. If applicable, I authorize each high school and each college or school I have attended to release academic and personal information, as well as my employer to verify my dates of employment. I agree to submit other materials that are required for an admission application. I agree that as a student I will be subject to The Ohio State University Code of Student Conduct. I understand that furnishing false or incomplete information on any part of this application material or other related materials may result in cancellation of admission or registration or both.

Signature: ______Date:______

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Check List for Credit Option OSU Application

(1) Application form: Completed and signed. Unsigned application form will not be processed.

(2) Official transcript(s): From ALL post-secondary institutions attended. You can use your OSU Advising Report as your OSU transcript.

(3) A non-refundable application fee of $40 payable to SPEAC, the Ohio State University.